Fillable Printable Employment Application Form for New York State
Fillable Printable Employment Application Form for New York State
Employment Application Form for New York State
NEW YORK STATE DEPARTME NT OF ENVI RONMENTAL CONSERVATI ON
DIVISION OF MANAGEMENT AND BUDGET SERVICES
BUREAU OF PE RSON NE L
EMPLOYMENT APPLICATION (HR-1)
AN EQUAL OP PORT UNITY/AFFIRMATIVE ACTION EM PLOYER
NAME (First, MI, Last)
Posting Number: ______________________________
Position applying for: _______________________________
Full-Time Part-Time Seasonal/Temporary
Location:
Date Available:
Social Security Number:
Phone nu mbers (include area cod e)
Dayt ime ( ) _______________________________________
Evenin g ( ) _______________________________________
EMAIL: _______________________________________________
MAILING ADDRESS : ( Street, City, State and Zip Code)
LEGAL AD DRESS ( if diffe rent from mailing a ddre ss)
Are you a NON-VETERAN
VETERAN
DISAB LED VETERAN
Do yo u claim Wartime Veteran Status? YES NO
If yes, dates o f active milita ry service
From __________________ To ______________________
Are you legally eligib le to work in the United State s?
YES NO
W ill you now, or in the future, r eq uire spo ns orship for employment
visa stat us ( e.g. H-1B visa st atus or NAFTA?)
YES NO
Are you at least 18 years of age?
YES NO
If under 18, do you have a wo rking per mit?
YES NO
Were you ever a Ne w Yo rk State emplo yee?
YES NO
If yes, title and dates o f employme nt
Are you o n any current NYS Civ il Se r vice e ligible lists?
YES NO
If yes, E xamination Title (s)
EDUCATION A ND TRAINING: If add itional space is required, attach a separate sheet
Do yo u have a H igh Sc hool or Gener al Eq uivalency D i pl oma? YES NO
If yes, name and location of high school or issuing govern ment author i ty:
College, University, Pro fessional or Technical
School(s)
Credits Received
Majo r Subject or
Type of Course
Type of
Degree
Received
Did you
Graduate?
Date
Degree
Expected
Name of Institution, Cit y and State
Number _______
Semester Hours
Quarter Hours
YES
NO
MO. / YR.
Name o f Institution, City and Sta te
Number _______
Semester Hours
Quarter Hours
YES
NO
MO. / YR.
List any o ther relevant trai nin g, c ourses, or skills:
LICENSE O R CERTIFIC ATION: Complete the following if a license, certificate or other authorization to practice a profession or
trade is required. If not currently licensed, check this box. D o you have a vali d dr iver’s license? Yes No
Driver License or Non-driver Photo ID Number ____________________ State _______
Name of Profession or Trade
License Nu mber
Grant ed By (Li censing Agency)
State
Specialty
Date License First Issued
Current Registration
From ( M O. /YR.) _________ _ ___ to ___ ___ _________
PREVIOUS EMPLOYMEN T: Be gin ning with t he most rece nt, list below all per iods o f employment, i ncludin g NYS employment
and service in the ar med force s. If additional space is required, attach a separate sheet.
Length o f Employment
(indicate Mo./Yr.)
From: T o:
Name of Busine ss Address City State
Earnings
$ Wk. Yr.
Type of Busine ss
Name and Title o f Supervisor
Your Title
Duties:
Reason for Leaving
Length o f Employment
(indicate Mo./Yr.)
From: T o:
Name of Busine ss Address City State
Earnings
$ Wk. Yr.
Type of Busine ss
Name and Title o f Supervisor
Your Title
Duties:
Reason for Leaving
Length o f Employment
(indicate Mo./Yr.)
From: T o:
Name of Busine ss Address City State
Earnings
$ Wk. Yr.
Type of Busine ss
Name and Title o f Supervisor
Your Title
Duties:
Reason for Leaving
ADDITIONA L QUESTIONS:
YES NO Wer e you ever discharged from any e mployment except for lack of work, funds, disability or medical condition?
YES NO Did you ever resign fro m any employment rather than face discharge?
YES NO Did you ever receive a discharge from the Armed Forces of the United States which was o ther than “Hono rabl e”
or which was issued under other tha n ho norable conditions?
YES NO Have you ever been convicted of any cri me (felon y or misdemeanor)?
YES NO Are you no w under charges for any crime?
If you answered “YES” to any of the above questions, please explain on a separate sheet. None of the above circumstances
represents an automatic bar to e mployment. Each case is considered and evaluated on individual merits in relatio n to the duties and
responsibilities of t he position(s) for which you are applying.
I certify that the information on this Employment Application, and attachments I provided, are correct to the best of my knowledge
and belief and that a false state ment knowingly made may be considered cause for revocation of appointment. I understand that any
informati on I give may be in vestiga ted.
Signature________________________________________________________________ Date ___________________________
PERSONAL PRIVACY PR OTECTION NOT IF ICATION
The information you are providing on this application is being requested pursuant to Section 50.3 of the New York State Civil Service Law for t he p r inc ipa l purpose of
determining eligibility for employm ent. Th e information may also be used in administering employee benefit pro g rams. In eit her c as e, it wil l be used in acc o r d ance
with Section 96(1) of the Personal Privacy Protection Law. Failure to provide the requested information may hinder your possi bl e hiring and the s ubse quent
administration of your employee benefits. The information will be maintained by the Department of Environmental Conservation , 625 Broadway, Albany, New York
12233-5060, (518) 4 02 -9273 or in a DEC Regional Office. 2/14
